Abstract
Objectives
To examine the feasibility, efficacy, and safety of sustained low-efficiency dialysis (SLED) in hemodynamically unstable, critically ill children.
Methods
Critically ill patients, 1–18 y old with hemodynamic instability (≥ 1 vasoactive drugs) and severe acute kidney injury (AKI) requiring kidney replacement therapy (KRT) in a tertiary care pediatric intensive care unit were prospectively enrolled. Patients weighing ≤ 8 kg or with mean arterial pressure < 5th percentile despite > 3 vasoactive drugs, were excluded. Patients underwent SLED until hemodynamically stable and off vasoactive drugs, or lack of need for dialysis. The primary outcome was the proportion of patients in whom the first session of SLED was initiated within 12 h of its indication and completed without premature (< 6 h) termination. Efficacy was estimated by ultrafiltration, urea reduction ratio (URR), and equilibrated Kt/V. Other outcomes included: changes in hemodynamic scores, circuit clotting, adverse events, and changes in indices on point-of-care ultrasonography and echocardiography.
Results
Between November 2018 and March 2020, 18 patients with median age 8.6 y and vasopressor dependency index of 83.2, underwent 41 sessions of SLED. In 16 patients, SLED was feasible within 12 h of indication. No session was terminated prematurely. Ultrafiltration achieved was 4.0 ± 2.2 mL/kg/h, while URR was 57.7 ± 16.2% and eKt/V 1.17 ± 0.56. Hemodynamic scores did not change significantly. Asymptomatic hypokalemia was the chief adverse effect. Sessions were associated with a significant improvement in indices on ultrasound and left ventricular function. Fourteen patients died.
Conclusions
SLED is feasible, safe, and effective in enabling KRT in hemodynamically unstable children with severe AKI.
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Acknowledgements
The authors acknowledge the commitment and support of the nursing staff of pediatric hemodialysis and intensive care units.
Funding
The Indian Council of Medical Research provided funding to the Advanced Center for Research in Pediatric Kidney Diseases, Division of Nephrology, Department of Pediatrics, AIIMS [5/7/1090/2013-RHN].
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MY made substantial contribution to the acquisition, analysis, and interpretation of data and drafted the manuscript; ANT and PK helped in clinical work; ANT supervised dialysis sessions; AS, PH, JS, RL, and AB made substantial contributions to the conception and design of the work; revised the work critically for important intellectual content. AB will act as the guarantor for this paper.
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Institute Ethics Committee, All India Institute of Medical Sciences, Ansari Nagar, New Delhi; IECPG-465/27.09.2018, RT-12/18.10.2018/RT-5/14.11.2018.
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Yadav, M., Tiwari, A.N., Lodha, R. et al. Feasibility and Efficacy of Sustained Low-Efficiency Dialysis in Critically Ill Children with Severe Acute Kidney Injury. Indian J Pediatr 90, 355–361 (2023). https://doi.org/10.1007/s12098-022-04214-z
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DOI: https://doi.org/10.1007/s12098-022-04214-z